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Prostate – Active Surveillance Patient Name Dear Patient Name TREATMENT SUMMARY You have now completed your initial treatment for cancer. This Treatment Summary provides a summary of your diagnosis, treatment and on-going management plan. It includes information on the symptoms you should be aware of, and who to contact. Your GP will also receive a copy of this summary. Diagnosis: Prostate Cancer Date of Diagnosis: Organ/Staging Local/Distant Summary of Treatment and relevant dates: Active Surveillance Possible Consequences of Continued Surveillance: Urinary symptoms (frequency, urgency, night time voiding) Erectile dysfunction Psychological issues Treatment Aim: You are on active surveillance because you have localised prostate cancer and may never need treatment unless your prostate cancer progresses Advise entry onto primary care palliative or supportive care register Yes / No DS 1500 application completed Yes/No Prescription Charge exemption arranged Yes/No Alert Symptoms that require referral back to specialist team: Contacts for re referrals or queries: In relation to post biopsy complications please attend your local A&E: Passing large blood clots or the feeling of being unable to pass urine. A high temperature/shivering/shaking In Hours: Other symptoms to seek advice about: A change in your urinary symptoms Pain in your lower back A sudden onset of weakness in your legs - URGENT Unintended weight loss (more than 3kg) Loss of appetite Secondary Care Ongoing Management Plan: (tests, appointments etc) Out of hours: Other service referrals made: (delete as nec) District Nurse AHP Social Worker Dietitian Clinical Nurse Specialist Psychologist Benefits/Advice Service Other Your urology consultant or nurse specialist will manage any other incidental symptoms e.g. urinary symptoms and erectile dysfunction Please get a PSA test taken with your GP every 6 months. It is your responsibility to ensure you have these PSA checks. If your PSA is more than __________please contact us on email____________________ or call us on XXXX patient name | date of birth | hospital number Your next MRI scan is due______________________. Your next biopsy will be considered_______________. You will be referred to our post treatment seminar session if you require any intervention for symptom control or support. Always have a PSA done at least one week prior to your outpatient appointment – please contact your GP to organise your PSA and bring the results with you to your appointment. Required GP actions in addition to GP Cancer Care Review (e.g. ongoing medication, osteoporosis and cardiac screening) Your urology consultant or nurse specialist will manage any other incidental symptoms e.g. urinary symptoms and erectile dysfunction Summary of information given to the patient about their cancer and future progress: Normal working hours: 9-5: Prostate Cancer Nurse Specialist: XXXXX Prostate Clinic Appointments: XXXXX Out of hours/emergencies: XXXX hospital switch board and ask for the on-call urology registrar Additional information including issues relating to lifestyle and support needs: Post treatment seminars on living & keeping well: eating well, keeping active, relationship counselling, psychologist (holistic needs). Managing the after effects of treatment: urinary symptoms, erectile dysfunction & hot flushes Support group (last Friday of the month 14:00 – 15:30) No referral required Other: Yours sincerely Electronically Approved By: PRIVATE AND CONFIDENTIAL cc. Patient GP Name Patient GP Address Patient GP Post Code Supporting Documents that may help – Please delete this section before giving to the patient Sexual Consequences for Men Prompt Tool (http://www.londoncanceralliance.nhs.uk/media/118596/lca-hna-male-sexual-consequencesjanuary-2016.pdf) Fatigue Prompt Tool (http://www.londoncanceralliance.nhs.uk/media/122127/lca-hna-fatigue-prompt-sheetjanuary-2016.pdf) Name | Date of birth | Hospital Number Pain Prompt Tool (http://www.londoncanceralliance.nhs.uk/media/122133/lca-hna-painprompt-sheet-january-2016.pdf) Name | Date of birth | Hospital Number GP READ CODES FOR COMMON CANCERS (For GP Use only). Other codes available if required. (Note: System codes are case sensitive so always ensure codes are transcribed exactly as below) System 1 Diagnosis: Lung Malignant Tumour Carcinoma of Prostate Malignant tumour of rectum Bowel Intestine Large Bowel Female Malignant Neoplasia Male Malignant Neoplasia Histology/Staging/Grade: Histology Abnormal Tumour grade Dukes/Gleason tumour stage Recurrent tumour Local Tumour Spread Mets from 1° Treatment Palliative Radiotherapy Curative Radiotherapy Chemotherapy Radiotherapy Treatment Aim: Curative procedure Palliative procedure Treatment toxicities/late effects: Osteoporotic # Osteoporosis Infection Ongoing Management Plan Follow up arranged (<1yr) Follow up arranged (>1yr) No FU Referral PRN Referrals made to other services: District Nurse Social Worker Nurse Specialist SALT Actions required by the GP Tumour marker monitoring PSA Osteoporosis monitoring Referral for specialist opinion Advised to apply for free prescriptions Cancer Care Review Palliative Care Review Medication: New medication started by specialist Medication changed by specialist Advice to GP to start medication Advice to GP to stop medication Information to patient: DS1500 form claim Benefits counselling Cancer information offered Cancer diagnosis discussed Aware of diagnosis Unaware of prognosis Carer aware of diagnosis Miscellaneous: On GSF palliative care framework GP OOH service notified Carers details (5 digit codes) XaOKG X78Y6 XE1vW X78gK X78gN B34.. B35.. 4K14. X7A6m XaOLF XaOR3 X7818 XaFr. 5149. XalpH x71bL Xa851 Xallm XaiL3 Xa1TO XaELC Xa9ua 8H8.. XaL.. 8HA1. 8HAZ. XaBsn XaBsr XaAgq XaBT6 Xalqg Xalqh XalSd Xalst 9D05 Xalyc XalG1 XEOhn 8B316 XaKbF XaJC2 All other systems Version 3 five byte codes (October 2010 release) Diagnosis Malignant neoplasm of bronchus or lung Malignant neoplasm of prostate Malignant neoplasm of Rectum Malignant neoplasm of Colon Malignant neoplasm of female breast Malignant neoplasm of male breast B22z. B46.. B141. B13.. B34.. B35.. Histology/Staging/Grade: Histology Abnormal Tumour staging Gleason grading of prostate Ca Recurrence of tumour 4K14. 4M… 4M0.. 4M6.. Metastatic NOS Treatment Radiotherapy tumour palliation Radiotherapy Chemotherapy BB13. 5149. 7M371 8BAD. Treatment Aim: Curative treatment Palliative treatment 8BJ0. 8BJ1. At risk of osteoporosis Osteoporosis 1409. N330. Ongoing Management Plan Follow up arranged 8H8.. No follow up arranged 8HA.. Referrals made to other services: Refer to District Nurse Refer to Social Worker 8H72. 8H75. Actions required by the GP Tumour marker monitoring PSA Osteoporosis monitoring 8A9.. 43Z2. 66a.. Entitled to free prescription Cancer Care Review Palliative Care Plan Review Medication: Medication given Medication changed 6616. 8BAV. 8CM3. 8BC2. 8B316 Information to patient: DS1500 completed Benefits counselling Cancer information offered Cancer diagnosis discussed 9EB5. 6743. 677H. 8CL0. XaJv2 Xaltp Miscellaneous: On GSF Palliative Care Framework GP OOH service notified 8CM1. 9e0.. 9180. Carer details 9180. XaCDx 6743. XalmL XalpL XaQly XaVzE XaVzA National Cancer Survivorship Initiative Name | Date of birth | Hospital Number December 2010